40 Hours Notification

NOTIFICATION OF PLANNED COMMUNITY INVOLVEMENT ACTIVITIES Student Name

Principal

Mr. P. Adam School Name

Telephone Number

Bishop Smith Catholic High School

735-5496

Please provide the information requested below about the community involvement activities in which you plan to participate. Estimated Number Of Hours

Name of Charity, Parish, Community Service Club, etc. and Description of Activity

Estimated Date of Completion

***Is each activity identified on the school board’s list of approved activities?

Location of Activity and Phone No.



Yes

Supervisor’s Name (Please Print)



Signature of Approval (Principal, Counsellor)

No

If you checked “No”, you must obtain written approval from the principal (the principal’s signature above) before starting the activity.

Student’s Signature

Date

Parent’s or Guardian’s Signature

In accordance with the Municipal Freedom of Information and Protection of Privacy Act, all personal information collected under the authority of the Education Act is intended to be used to determine eligibility for selection and participation in the Community Involvement Activities Program, which is required for an Ontario Secondary School Diploma.

Date